00008458 (MISC) RIVCOCountyofRiverside
Department of Building and' Safety
4000 Lemon SL, 2nd Floor 135 N. Alessandro,Rd. Am. 203 Soo N. State Street 227' North "D" Street 46209 Oasis St.,Rm. 310 160 N. Broadway
Riverside. CA 92501 Bans 2220 CA 9Hemel CA 92343 Perris, CA' S= Indlo, OA 92201 Blythe; CA 92 5
Ph: M-6145 Ph: 6197312 Ph, 65044M Ph: W489 P t 342-e271 Phr. 9*2670
This permit becomes void i1work not commenced within 180 days from date o1 issuance,, OR, It work his been suspended or abandoned for a period of 160 days.
.10ENSED CONTRACTORS DECLARATION: hereby affirm that I am licensediunder provisions of Chapter'9 (commeocing
vith flection 700M of Division 3 of the Business and Protasslons,Code; and my license is in full tones and eBecL
(cense Claes tie. Number.
lata. Contractor
IWNE"UILDER DECLARATION: I hereby affirm that I and exempt from the Contractor3 License Law for thafollowing
salon (Sec. 7031.5, Business and Professions Cope: Anyctty or county which requires r permit to, construct, alter,
mprove, demolish, or, repair any structure, prlor,to Its Issuance, also requires the applicant tot such,perm)t to file a
dgned statement,thalhe Is4ieenset pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing
vith,Seclion 7000) of Division 3 of.me Business and Professl6wCode) or that hefrakempt therefrom and, the basis for
he ellegeo ekemption, Any vldlatlon of :Section 70..5 by any applicant far a perrdil subjects the applicant to a,elvif
Ienalty of, mi more, than five hundred dollars 1860WJ:
]. 'I, as owner of the property, or my employees with wages'as their sole. compensation, will do the. work, and,ths
Itructure is not intended or offered for sale (Sec. 7044, Business and Profeeaions,Code; ThaContractbr's License Law
lose not apply to an owner of property wins pullds or Improves thereon,'lind who doetsueh work himself or through
tis oW-n employee!, provided that such Improiamentg are; not intended or oifered forsale. If. however, the building or
mprovemeot is sold'within ane year oi.complekon, the owner-twilderwill havetheburden of proving that, he dWnot
mild or improve for the purpose of sa)e:).
]� I,,,as owner of the.property am exctusivelyx:onlracting with-Ilcelssd�contractors� to'construct the project (Sec. 7044.
3usiness and Professions Code: Thetontrectores Lfconse'Law does' not apply Wan owner ol'property 00 builds or
mpioves thereon, and who contracts for guch,projects with a contractor(s) licensed pursuant to the Contractor's
!cense Law.),
], 1 am.exempt under Set , B..6,PIC. (Attach Certilicite).
We owner. -
NORKERS' COMPENSATION DECLARATIOM I hereby affirm that.I have a certificate of consent to self -Insure, or, a
certificate of Workers'' Compensation Insurance.,or a.certified copy thereof (Seam 3600. Lab. C.).
Policy Nm Company
] Certified copy is hereby furnished.
] Willed copy is filed with'[he County Building Inspection Department or County Department.
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CERTIMCATEAF.EXEMPTiON FROM WORKERS' COMPENSATION INSURANCE: This aectloAneed not be completed If the
Permit to for one hundred (S100) or Inc. 'I certify that in the psrformana:of the work for which this permit Is Issued, l
shall not employ any person In any manner so as to become subject to the Workers' Compensation Lan of,Callfornls.
Date Applicant
NOTICETOAPPLICANT: It, after making -this Certificate of Exemption, you should become subject tome Workers'
Compensation, provisions. of the labor Code. you must forthwith coinply'wfth such provislorq or thls permit shell be
deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
f(""� I,hereby:certity that ca
no excavation five l or more:teetin depth Into which.a person is required to descend. will be
,m'Eda In-connectlom with work wthorked �y this permit. And that no buildlnp strnoN scaffofdlnp Millwork. or
demolition or dismanUing thereof, will fie more than thirty-six (36) test high. (Chap 32. Gto 2. Art 2, Sec 341, Title fL
C.A.C.)
R As owner -builder. I will mot employ anyone to. do work which would'requirs a permit from the Division of Industrial
Safety, as noted above, unless such person, has a permit to do such work from that division.
Q, Division of industrial Safety Permit No,
Date Applicant
CONSTRUCTION !ENDING AGENCY: I hereby affirm, !het there is a construction lending agency for the performance of
the work "for which this permit is issued (Sec. 3097. Div. C.).
Lender's Name
Lenders Address
I,certity that I have read this application; and slate -that the above lfnfor�ation Is correct. I agree to comply with all
city' and county ordinances. and slate laws relating to building construction, and hereby authorize representatives of
this county twenter upon the above•mentionsd property for Inspection purposes.
Signature of, Applicant or Agent Data
CERTIFICATE OFCOMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have road this application and stale that the.
information given'rs correct. I. agree,to comply with all:eete laws,and county ordinances relating to building can-
structlon, and. authorize a,representative of the County,ol Riverside, Department of Budding and Safety to enter upon
the property for which, I,bays .applied for this permit forr the purpose of making inspections,
Signature of Applicant or Agent Date .
Print Applicant/Agent Name
A"Rib4se is - it/PS 25q&Tk/01 011070_
APPLICATION FOR GRADING PLAN REVIEW
ASSESSOR COPY T TAA
APPLICATION FOR GRADING PLAN REVIEW
T H T C I G A 14
AP P L'I CAT 1 ON ONLY
011070